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07/02/14
1
Jumpers knee
Myles Coolican
Val d’Isere 2014
Background information patellar tendinopathy Structure of PT Pathophysiology Prevalence Risk factors Imaging Non Operative management
Newer injectables -‐do they work -‐what is the evidence Surgery
Jumpers Knee-‐ Overview
* Jumping athletes –Martin Blazina 1973 * Anterior knee pain and tenderness * Patellar tendinopathy * Proximal, central, posterior portion of tendon * Aetiology * Overuse * High impact ballistic loading * Tensile Load * Patellar Impingement
Jumper’s knee
* Blazina M, Kerlan R, Jobe F, et al: Jumper’s knee. Ortho Clin North Am 4:665-‐678, 1973
* Lesion is proximal posterior central * Why here-‐-‐-‐-‐-‐-‐Unknown * Theories Posterior impingement Greater load Fibres here are shorter but with similar elongation under load Hamilton-‐adaptive response to compression loads
Jumper’s knee
Andrew Amis
* Applied 1KN to 10 cadaver knees-‐strain
Anterior Posterior 10 3.9% 4.9% 60 2.7% 4.6% 90 1.7% 3.2%
Loads on patellar tendon
Repetitive overload * Microscopic tears * Mucoid degeneration * Fibrinoid necrosis * Collagen separation / collagen degeneration * * Regional variation in vascularity / neovascularity * Pain mediated by glutamate and other non-‐prostaglandin pathways **
Pathophysiology
* Khan K et al. Histopathology of common tendinopathies. Update and implications for clinical management. Sports Med. 1999;27(6):393-‐408. ** Alfredson H et al. In vivo microdialysis and immunohistochemical analyses of tendon tissue demonstrated high amounts of free glutamate and glutamate NMDAR1 receptors, but no signs of inflammation, in jumper’s knee. J Orthop Res. 2001;19(5):881-‐886.
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Prevalence
Lian OB, Engebretsen L, Bahr R. Prevalence of jumper’s knee among elite athletes from different sports: a cross-‐sectional study. Am J Sports Med. 2005;33(4):561-‐567.
613 Norwegian national elite athletes 50 symptomatic Oslo, Norway
2005
* Overall prevalence 14% * Previous symptoms 8% * Career prevalence 22%
* Male 2 : 1 Female
* Variations between sports
* Duration of symptoms * 32 ± 25 months
Prevalence
Lian OB, Engebretsen L, Bahr R. Prevalence of jumper’s knee among elite athletes from different sports: a cross-‐sectional study. Am J Sports Med. 2005;33(4):561-‐567.
* Weight * Height * Weight training * Jump training * Waist-‐to-‐hip ratio
Risk Factors
Lian OB, Engebretsen L, Bahr R. Prevalence of jumper’s knee among elite athletes from different sports: a cross-‐sectional study. Am J Sports Med. 2005;33(4):561-‐567. Ven der Worp H et al. Risk factors for patellar tendinopathy: a systematic review of the literature. Br J Sports Med 2011; 45: 446-‐452
* Leg length difference * Arch height of foot * Quads flexibility * Hamstring flexibility * Quads strength
* Weight * Height * Weight training * Jump training * Waist-‐to-‐hip ratio
Risk Factors
Lian OB, Engebretsen L, Bahr R. Prevalence of jumper’s knee among elite athletes from different sports: a cross-‐sectional study. Am J Sports Med. 2005;33(4):561-‐567. Ven der Worp H et al. Risk factors for patellar tendinopathy: a systematic review of the literature. Br J Sports Med 2011; 45: 446-‐452
* Leg length difference * Arch height of foot * Quads flexibility * Hamstring flexibility * Quads strength
Risk Factors
Jumping Sports
Imaging
Warden S et al: Comparative accuracy of magnetic resonance imaging and ultrasonography in confirming clinically diagnosed patellar tendinopathy. Am J Sports Med 35:427-‐436, 2007
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MRI V Ultrasound
* Level 2 evidence – Cohort Study * 30 clinical patellar tendinopathy * 33 asymptomatic, activity matched
* MRI * GS-‐US Grayscale Ultrasound * CD-‐US Colour Doppler Ultrasound
Warden S et al: Compara7ve accuracy of magne7c resonance imaging and ultrasonography in confirming clinically diagnosed patellar tendinopathy. Am J Sports Med 35:427-‐436, 2007
Imaging
Warden S et al: Comparative accuracy of magnetic resonance imaging and ultrasonography in confirming clinically diagnosed patellar tendinopathy. Am J Sports Med 35:427-‐436, 2007
MRI V Ultrasound
* Ultrasound more accurate than MRI to confirm clinically diagnosed patellar tendinopathy
* GS-‐US greatest sensitivity
* CD-‐US indicated likelihood of being symptomatic
Imaging
Warden S et al: Comparative accuracy of magnetic resonance imaging and ultrasonography in confirming clinically diagnosed patellar tendinopathy. Am J Sports Med 35:427-‐436, 2007
MRI V Ultrasound
* Need a good radiologist * How often do we see an US film on screen in OR?
Imaging
* Victorian Institute of Sport Assessment (VISA) Score
Clinical scoring system
0 100
Most Symptomatic Asymptomatic
Management
Universal agreement * First 6 months * Non operative treatment
Fig: ElaLrache NS. Percutaneous Ultrasonic Tenotomy as a Treatment for Chronic Patellar Tendinopathy—Jumper’s Knee. Opera7ve Techniques in Orthopaedics. 2013 23(2) 98-‐103
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Non Operative Management
* Avoidance of painful activities * Physiotherapy * NSAIDS * Extra corporeal shock wave * Low level laser * Injections Management of Chronic Tendon Injuries. www.aafp.org/afp
Non Operative Management
Physiotherapy * Eccentric strengthening program * Therapeutic Ultrasound * Iontophoresis-‐electricity deliver * Phonophoresis-‐US deliver * Topical nitroglycerine
Bahr R et al. Surgical Treatment Compared with Eccentric Training for Patellar Tendinopathy (Jumper’s Knee). JBJS(Am) 2006 88(8) 1689-‐1698
Non Operative Management
Eccentric Quads V surgery
Bahr R et al. Surgical Treatment Compared with Eccentric Training for Patellar Tendinopathy (Jumper’s Knee). JBJS(Am) 2006 88(8) 1689-‐1698
Surgery = Open patellar tendon debridement
Non Operative Management
Bahr R et al. Surgical Treatment Compared with Eccentric Training for Patellar Tendinopathy (Jumper’s Knee). JBJS(Am) 2006 88(8) 1689-‐1698
* No advantage of surgical treatment over eccentric exercise program
* Trial of eccentric exercises for 12 weeks before considering open tenotomy
Non Operative Management
Bahr R et al. Surgical Treatment Compared with Eccentric Training for Patellar Tendinopathy (Jumper’s Knee). JBJS(Am) 2006 88(8) 1689-‐1698
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Non Operative Management
NSAIDS * Widespread use * Little evidence of efficacy in chronic tendinopathy * * Associated risks * GI upset * Renal damage * Increased cardiovascular risk
* Mehallo CJ et al. Practical management: nonsteroidal anti-‐inflammatory drug (NSAID) use in athletic injuries. Clin J Sport Med. 2006;16(2):170-‐174.
Non Operative Management
Injections * Corticosteroid injection * Prolotherapy-‐injections stimulate collagen * Plasma Rich Platelet injections
Fig: ElaLrache NS. Percutaneous Ultrasonic Tenotomy as a Treatment for Chronic Patellar Tendinopathy—Jumper’s Knee. Opera7ve Techniques in Orthopaedics. 2013 23(2) 98-‐103
Corticosteroid Injection
* 7 weight lifters over a 2 year period * Average of 9 steroid injections * No other risk factors for rupture * Mean loss of 8% of power of knee extension 2 years after surgical repair
Kaohsiung Medical University Hospital, Taiwan Hoksrud A, et al. Ultrasound-‐Guided Sclerosing Treatment in Pa7ents With Patellar Tendinopathy (Jumper's Knee) 44-‐Month Follow-‐up. AJSM 2011 39(11) 2377-‐2380
US Guided Sclerosing treatment
US Guided Sclerosing Treatment
Prolotherapy * Polidocanol injected into area of neovascularisation * VISA score pre, 12, 44 months * 29 patients * 12 patients required arthroscopic surgery during f/u * Effective for a little over half the patients * Other patients had significant improvement in VISA score
Hoksrud A, et al. Ultrasound-‐Guided Sclerosing Treatment in Pa7ents With Patellar Tendinopathy (Jumper's Knee) 44-‐Month Follow-‐up. AJSM 2011 39(11) 2377-‐2380
Vetrano M et al. Platelet-‐Rich Plasma Versus Focused Shock Waves in the Treatment of Jumper’s Knee in Athletes. AJSM 2013 41(4) 795-‐803
Platelet Rich Plasma
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* 46 consecutive athletes * Randomized to 2 treatment groups * 2 autologous PRP injections over 2 weeks * 3 sessions of ESWT
* Both groups had significant improvement in symptoms * No difference between groups at 2 months * PRP group significantly better at 6 and 12 months
Platelet Rich Plasma
Vetrano M et al. Platelet-‐Rich Plasma Versus Focused Shock Waves in the Treatment of Jumper’s Knee in Athletes. AJSM 2013 41(4) 795-‐803
Platelet Rich Plasma
Better
* Filardo 2009 and 2013 * Kon 2008
Worse
* Bowman-‐2013 Pittsburgh 3 patients worse
Vetrano M et al. Platelet-‐Rich Plasma Versus Focused Shock Waves in the Treatment of Jumper’s Knee in Athletes. AJSM 2013 41(4) 795-‐803
* US guided percutaneous tenotomy * Arthroscopic debridement * Open debridement * Combined arthroscopic and open debridement
Surgical Management
ElaLrache NS. Percutaneous Ultrasonic Tenotomy as a Treatment for Chronic Patellar Tendinopathy—Jumper’s Knee. Opera7ve Techniques in Orthopaedics. 2013 23(2) 98-‐103
Surgical Management
Percutaneous Ultrasonic Tenotomy
ElaLrache NS. Percutaneous Ultrasonic Tenotomy as a Treatment for Chronic Patellar Tendinopathy—Jumper’s Knee. Opera7ve Techniques in Orthopaedics. 2013 23(2) 98-‐103
16 pa7ents 15 “some level of improvement” 10 “returned to prior level of compe77on”
Open or Arthroscopic * Longitudinal tenotomy * Debride macroscopically abnormal tendon * Inferior pole of patella excision * Inferior pole of patella drilling / microfracture * Paratenon repair / excision / leave open * Fat pad excision * Synovectomy * Associated chondral / meniscal lesions
Surgical Management
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Pascarella, Antonio, et al. "Arthroscopic management of chronic patellar tendinopathy." The American journal of sports medicine 39.9 (2011): 1975-‐1983.
Surgical Management
Pascarella, Antonio, et al. "Arthroscopic management of chronic patellar tendinopathy." The American journal of sports medicine 39.9 (2011): 1975-‐1983.
• 64 patients (73 knees) failed non-‐operative management • 27 professional athletes • Arthroscopic Debridement:
• Fat pad • Patellar tendon • Lower pole of patella
• VISA scores improved significantly at 1,3,5 and 10 years. • Return to sport at 3 months • 19 of 27 elite athletes returned to same level of sport
Surgical Management
Cucurulo, T et al(2009). Surgical treatment of patellar tendinopathy in athletes. A retrospective multicentric study. Orthopaedics & Traumatology: Surgery & Research, 95(8), 78-‐84.
64 athletes recalcitrant to conservative management Average 22 month follow up
87% patients improved 63% returned to previous level of sport
No difference between patellar resection and arthroscopy
Surgical Management
Kaeding CC, Pedroza AD, Powers BC. Surgical treatment of chronic patellar tendinosis: a systematic review. Clin Orthop Relat Res. 2007;455: 102-‐106.
• Paucity of good quality research • Highest level of evidence – Level IV (case series) • Systematic Review
• Surgical treatment of inferior pole of patella • Closure of paratenon • Immobilization
Surgical Management
Kaeding CC, Pedroza AD, Powers BC. Surgical treatment of chronic patellar tendinosis: a systematic review. Clin Orthop Relat Res. 2007;455: 102-‐106.
Inferior Pole of Patella Excise inferior pole of patella?
Impinging lesion Drill the inferior pole?
Encourage blood flow / healing More successful outcomes without bony work 97.1% V 70.9%
Surgical Management
Kaeding CC, Pedroza AD, Powers BC. Surgical treatment of chronic patellar tendinosis: a systematic review. Clin Orthop Relat Res. 2007;455: 102-‐106.
Paratenon Close the paratenon ?
Encourage healing Excise the paratenon?
Remove pain fibres More successful outcomes without closure 91.5 V 84.8% with closure
Surgical Management
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Kaeding CC, Pedroza AD, Powers BC. Surgical treatment of chronic patellar tendinosis: a systematic review. Clin Orthop Relat Res. 2007;455: 102-‐106.
Immobilization after surgery Utilized in 4 studies
Success rate 84.8% No immobilization in 4 studies
Success rate 91.5% More successful outcomes without immobilization
Surgical Management
* Common in jumping sports * Affects deep proximal patellar tendon * Non operative management for first 6 months * PRP and sclerosing injections can be effective * Surgery reserved for failure of non op management * Paucity of good studies confirming what aspect of surgery helps the patient
Summary-‐jumpers knee
Thank you